Predominant age: Onset <7 years old; lasts into adolescence and adulthood; 50% meet diagnostic criteria by age 4 years.

Predominant sex: Male > Female (5:1); predominantly inattentive type may be more common in girls.

Incidence

5% of school-aged children

Risk Factors

Family history

Comorbid conditions (associated with, but not caused by):

Learning disabilities

Mood disorders

Oppositional defiant disorder

Conduct disorder

Genetics

Familial pattern

General Prevention

Children are at risk for abuse, depression, and social isolation.

Parents need regular support and advice.

Parents should establish contact with teacher each school year.

Commonly Associated Conditions

See Risk Factors

Diagnosis

American Academy of Pediatrics (AAP) guidelines recommend using the DSM-IV criteria to establish the diagnosis.

Children undergoing extreme stress (divorce, illness, homelessness, abuse) may demonstrate ADHD behaviors secondary to stress. This can be assessed using the American Academy of Child and Adolescent Psychiatry (AACAP) screening tool, if needed.

If diagnostic behaviors are noted in only one setting, explore the stressors in that setting.

The diagnostic behaviors are more noticeable in tasks that require concentration or boredom tolerance than in free play or office situations.

DSM-IV criteria: 6 or more inattention criteria and/or 6 or more hyperactivity/impulsivity criteria. Symptoms must begin by age 7 years, be present for >6 months, and be noticed in 2 settings (e.g., home and school). Teachers and caretakers should fill out assessments in addition to parents.

Inattention:

Careless mistakes in tasks

Difficulty in sustaining attention

Does not seem to listen

Does not follow through or finish tasks

Difficulty in organizing tasks

Avoids tasks that require sustained mental effort

Loses things

Easily distracted

Forgetful

Hyperactivity/impulsivity:

Fidgets

Difficulty in remaining seated

Runs or climbs excessively

Difficulty in playing quietly

Acts as if “driven by a motor”

Talks excessively

Blurts out answers before question is complete

Has difficulty in awaiting turn

Interrupts others

History

Birth and development history

Comprehensive psychosocial evaluation of home environment

School performance history

Diagnostic Tests & Interpretation

Behavioral testing:

Behavior rating scales (Connors, others) should be completed by parents and teachers. They are repeated after therapy is started to gauge differences (DSM-IV criteria can be used).

Patients with a personal or family history of congenital heart disease or sudden death should be screened with an electrocardiogram (EKG) and possible cardiology consultation before beginning stimulant medication (1).

The 2001 AAP guideline recommends (1)[C] the use of stimulant medications as 1st-line in treatment. A 2nd type of stimulant should be tried if the 1st treatment fails.

Alert

The Food and Drug Administration (FDA) has considered applying a “black box” warning to stimulants based on some reported cases of sudden death seen in patients using stimulant medications. It recommends that patients with a personal or family history of congenital heart disease or sudden death be screened with an EKG and possible cardiology consultation before beginning stimulant medication.

Atomoxetine carries a “black box” warning regarding potential exacerbation of suicidality (similar to selective serotonin reuptake inhibitors). Because of this, the manufacturer recommends weekly visits for 4 sessions, then every-other-week visits for 4 sessions, then every-12-weeks visits. Atomoxetine has also been associated with hepatic injury in a small number of cases, and the manufacturer recommends checking liver enzymes if symptoms (jaundice, fatigue, malaise) develop.

Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:894–921.

Related

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